Fee-basis: Putting the patient first

The American Legion has made several recommendations to Congress on how the Department of Veterans Affairs (VA) fee-basis program can be improved.

Jacob Gadd, deputy director of health for the Legion’s Veterans Affairs & Rehabilitation Division, presented the Legion’s testimony Sept. 14 at a hearing before the House Committee on Veterans’ Affairs (HCVA) subcommittee on health.

The fee-basis program uses health-care providers in the private sector to care for veterans who are unable to receive the treatments they need from VA facilities. Perhaps a veteran’s location is simply too inaccessible, or a non-VA provider’s services are more appropriate for the medical condition being treated.

Last April, Western Region National Vice Commander Merv Gunderson testified at an HCVA field hearing in Billings, Mont., that focused on ways access to VA health care for rural veterans could be improved. Gunderson urged VA to reconsider its policies for purchasing health care in the private sector so hospital chiefs of staff could use more discretion “to prevent veterans from being forced to drive hours to a facility for several routine and reoccurring appointments.”

A need exists for VA to further develop its fee-basis policies so they focus more upon the strategy of patient-centered care, the Legion said. The new policies should be well defined, consistent and capable of handling the increase in private-sector care purchased by VA.

In the past four years, non-VA purchased care has doubled from $2.2 billion in fiscal 2007 to $4.5 billion in fiscal 2011. In that same time period, the number of veterans being treated in the private sector rose from about 615,000 to more than 970,000.

VA hospital directors and finance staff have told members of the Legion’s System Worth Saving (SWS) task force that fee-basis care makes up between 15 and 25 percent of their budgets, and it continues to grow. In an effort to reduce such costs, VA is developing a Patient-Centered Community Care (PCCC) program. Its goal is “to provide veterans coordinated, timely access to high-quality care from a comprehensive network of VA and non-VA providers.”

While the Legion sees the PCCC program as a step in the right direction, it noted in its testimony that VA needs to bear in mind that all fee-basis coordination cannot be managed at a strictly national level. Many rural areas lack specialty or even primary-care providers, so VA facilities still need to work with smaller private-practice resources, “which may be the only option in a community, and especially rural areas.”

The PCCC program needs to guarantee that veterans are receiving the same quality of care – or better – than they would get from VA facilities and staff. While the SWS task force has heard from many veterans that their fee-basis care “has been great and they were treated close to their home,” the Legion also expressed several concerns to the subcommittee, including:

• The lack of VA education and training programs for private-sector providers.
• Computer systems of private-sector providers are not integrated with VA’s Computer Patient Record System (CPRS).
• Lapsing of VA’s fee-basis contract with Martha’s Vineyard Hospital in Massachusetts.

Physicians in private practice may not be prepared to treat certain conditions that are prevalent among veterans, such as post-traumatic stress disorder and other mental health disorders. They also may be unfamiliar with VA treatment resources for such conditions. If non-VA providers had formal training and education programs for service-connected illnesses and injuries, they would help to ensure the same quality of care standards and treatments of VA providers.

VA also needs to develop military culture and awareness training for private-sector providers, including gender-specific care for women veterans.

Community health-care providers need access to the CPRS so they can review the complete medical history of patients, make proper diagnoses, and develop effective treatment plans. Such access will also help non-VA providers meet quality-of-care measures that are tracked in the system, as well as speed up the documentation process.

During a site visit to Martha’s Vineyard Hospital in 2011, the Legion’s SWS task force found out that the facility’s fee-basis contract with the VA medical center in Providence, R.I., had lapsed. As a result, veterans living on the island were being billed for services previously covered by VA.

Since 2008, veterans were forced to travel by ferry and car to the VA facility in Providence. After long negotiations, VA has signed another contract with Martha’s Vineyard Hospital and, starting Oct. 1, veterans will once again receive fee-basis services and treatment.

The lesson to be learned from the Martha’s Vineyard incident is that interruptions in VA fee-basis contracts with community providers — especially in rural or isolated areas — translates into hardship and frustration among the veterans population.

The American Legion wants VA to develop and implement a tracking system to ensure that VA fee-basis contracts with the private sector remain current and do not lapse.

During the hearing, Rep. Michael Michaud shared The American Legion’s concerns over the Martha’s Vineyard incident and thanked the Legion for its SWS program that evaluates annually the quality of care being delivered by VA medical facilities to America’s veterans.

For a copy of Gadd's written testimony, click here.